The quality of immediate postoperative radiographs, performed after total hip replacement in the operating room versus in the post-anesthesia care unit: is there a difference?

INTRODUCTION: Currently, there are no clear guidelines regarding the optimal settings for immediate postoperative imaging following total hip arthroplasty (THA). Authors' primary aim was to determine the preferred setting for postoperative radiographs by comparing a technical quality of imaging performed in postanesthesia care unit (PACU) versus operating room (OR). MATERIALS AND METHODS: Our study is a retrospective comparison of quality of postoperative radiographs following THAs, performed in PACU versus OR. The evaluated factors included a technical quality (penetration, collimation and presence of foreign bodies), proper patient positioning, and clinical significance of the imaging expressed in number of decisions to perform immediate revision surgery that were based on postoperative imaging. RESULTS: 267 radiographs of patients who underwent primary unilateral THA were evaluated (139 performed in PACU and 128 in OR). In terms of technical quality, PACU radiographs were characterized by better penetration (69.1% vs 27.3%, p < 0.001) and less foreign bodies in the field (95.7% vs 83.6%, p < 0.001), but less adequate collimation (41.7% vs 79.7%, p < 0.001). There was a significant difference in the number of radiographs obtained without any noteworthy technical errors - 24 (17.3%) in PACU group vs 10 (7.8%) in OR group. CONCLUSION: Postoperative X-rays performed in the PACU were characterized by better technical quality compared to postoperative radiographs performed in OR. We, therefore, suggest to perform immediate postoperative evaluation in PACU to provide baseline radiographs of higher quality for future follow-up.

Efficacy of single-shot adductor canal block before Versus after primary total knee arthroplasty - Does timing make a difference? A randomized controlled trial.

BACKGROUND: Total knee arthroplasty (TKA) is associated with severe postoperative pain. Multimodal analgesia, including peripheral nerve block, is recommended for post-operative pain relief. Administration of some pain medications prior to surgery has shown to be more effective than after the operation. This is a prospective, randomized controlled trial designed to compare the analgesic efficacy of the adductor canal block (ACB) performed immediately before or immediately after primary total knee arthroplasty (TKA). We hypothesized that ACB before the surgery will reduce postoperative pain and improve knee function. METHODS: A total of 50 patients were enrolled and randomized into 2 groups, with 26 patients receiving a preoperative ACB and 24 receiving a postoperative ACB. RESULTS: Treatment groups were similar in terms of gender (p = .83), age (p = 0.61) weight (p = .39) and ASA score. Average visual analogue scale (VAS) on arrival to the post-anesthesia care unit (PACU) were 4.9 ± 3.2 in the preoperative ACB versus 3.4 ± 2.8 for the postoperative ACB (p = .075). VAS scores at different time points as well as the mean, minimal and maximal reported VAS scores were not significantly different between the two groups. The cumulative quantities of Fentanyl administered by the anesthesia team was comparable between the groups. Similarly, the dosage of Morphine, Tramadol, Acetaminophen and Dipyrone showed only small variations. The Quality of Recovery Score, Knee Society Scores and knee range of motion did not differ between the groups. CONCLUSIONS: Our findings demonstrate no significant differences in patient total narcotics consumption, pain scores and functional scores, between preoperative and postoperative ACB in patients undergoing TKA. TRIAL REGISTRATION: The trial was registered at www.clinicaltrials.gov and was assigned the registration number NCT02908711. LEVEL OF EVIDENCE: level I randomized controlled trial.

Earlier Initiation of Postoperative Physical Therapy Decreases Opioid Use after Total Knee Arthroplasty.

For patients with advanced osteoarthritis of the knee, total knee arthroplasty (TKA) has been shown to provide significant pain relief and improved function with consistent, reproducible results. Post-operative physical therapy (PT) plays an important role is restoring muscle strength and range of motion (ROM). Yet, the impact of earlier physical therapy initiation after TKA has not been well defined. We assessed 205 patients that underwent primary TKA including 136 patients who started PT on the first post-operative day (POD1) and a second group that started PT 3 days after surgery (POD3), or later. Length of hospital stay (LOS), opioid use during hospital stay, complications, re-admissions, knee ROM and the need for subsequent hospitalized rehabilitation were recorded. LOS was not significantly shorter in the early PT group, compared with the delayed PT group (6.4 ± 2.2 days vs. 6.8 ± 2 days, respectively, P = .217). Patients in the delayed PT group consumed more opioids during their inpatient stay compared with the early PT group on both POD 3 (89% vs 82%, p = 0.013) and POD 4 (81% vs 66%, p = 0.005). There was no significant difference in the incidence of Immediate post-operative complications or final knee ROM between the two groups. While early postoperative PT did not impact hospital LOS or final knee ROM, it was associated with an earlier reduction in postoperative opioid consumption after primary TKA.

Mild radiographic osteoarthritis is associated with increased pain and dissatisfaction following total knee arthroplasty when compared with severe osteoarthritis: a systematic review and meta-analysis.

PURPOSE: The association between severity of radiographic osteoarthritis with patient pain, function, and satisfaction following total knee arthroplasty has been disputed. The discrepancies in current literature prompt us to further examine this association in a systematic review and meta-analysis. METHODS: The OVID-Medline, Embase, and Web of Science databases were searched from their inception up to Mar 2020. The main independent variable was osteoarthritis severity as defined by preoperative radiographs. The outcomes measured were pain, function and satisfaction following total knee arthroplasty. A minimum of three studies assessing the same patient-reported outcome measures were included in the meta-analysis, as well as those separating patients by chronic pain or dissatisfaction. RESULTS: 29 studies were included in this study. Significant heterogeneity was seen between radiographic evaluation and reported outcomes. Patients with only mild radiographic osteoarthritis were more likely to suffer from chronic pain (odds ratio = 2.45, 95% CI = 1.80-3.34, p < 0.001) and dissatisfaction (odds ratio = 2.43, 95% CI = 1.79-3.31, p < 0.001) compared to patients with severe osteoarthritis. A significant association was found between mild radiographic severity and lower total Western Ontario and McMaster Universities Osteoarthritis scores (95% CI = - 0.37-0.06, p = 0.006) as well as Knee Society Scores (CI: - 0.54-0.16, p < 0.001). CONCLUSION: Patients with mild radiographic osteoarthritis are anticipated to gain less from total knee arthroplasty compared to those with severe osteoarthritis. They are also at risk for chronic pain and dissatisfaction and should be consulted about this risk prior to surgery. LEVEL OF EVIDENCE: III.

Lateral Column Lengthening for Flexible Flat Foot: Was It Short to Begin With?

BACKGROUND: Flexible flatfoot (FF) is a common foot deformity that can often consist of foot pain. Surgical treatment is designed to lengthen the lateral column. OBJECTIVES: To resolve whether radiographic standing feet measurements of normo-plantigrade feet and FF, symptomatic or not, differ and to determine whether the lateral column is shorter. METHODS: The study comprised 72 patients (127 feet) consecutive patients, 18 years of age and older, who were divided into three groups: normal feet (56), asymptomatic FF (29), and symptomatic FF (42). All patients had a standing anterior posterior (AP) and lateral radiographs. AP images were used for the measurement of the talocalcaneal angle, talar-1st metatarsal angle, and talonavicular coverage. Lateral X-rays were used to estimate the talocalcaneal angle, talar-1st metatarsal angle, calcaneal pitch, naviculocuboid overlap, and column ratio. RESULTS: All three of the AP radiograph measurements differed among groups, and higher values were measured in the symptomatic FF group. Post hoc analysis found that the talonavicular coverage and the talocalcaneal angles also differed between symptomatic and asymptomatic FF patients. While some lateral measurements differed within groups, only the lateral talar-1st metatarsal angle distinguished between asymptomatic and symptomatic patients. The lateral column length was not found to be shorter among FF patients, weather symptomatic or not. CONCLUSIONS: Only the talonavicular coverage, the AP talocalcaneal, and the lateral talar-1st metatarsal angles were found to differ between asymptomatic and symptomatic FF patients. The lateral column was not found to be shorter.

Biocompatibility of a Marine Collagen-Based Scaffold In Vitro and In Vivo.

Scaffold material is essential in providing mechanical support to tissue, allowing stem cells to improve their function in the healing and repair of trauma sites and tissue regeneration. The scaffold aids cell organization in the damaged tissue. It serves and allows bio mimicking the mechanical and biological properties of the target tissue and facilitates cell proliferation and differentiation at the regeneration site. In this study, the developed and assayed bio-composite made of unique collagen fibers and alginate hydrogel supports the function of cells around the implanted material. We used an in vivo rat model to study the scaffold effects when transplanted subcutaneously and as an augment for tendon repair. Animals' well-being was measured by their weight and daily activity post scaffold transplantation during their recovery. At the end of the experiment, the bio-composite was histologically examined, and the surrounding tissues around the implant were evaluated for inflammation reaction and scarring tissue. In the histology, the formation of granulation tissue and fibroblasts that were part of the inclusion process of the implanted material were noted. At the transplanted sites, inflammatory cells, such as plasma cells, macrophages, and giant cells, were also observed as expected at this time point post transplantation. This study demonstrated not only the collagen-alginate device biocompatibility, with no cytotoxic effects on the analyzed rats, but also that the 3D structure enables cell migration and new blood vessel formation needed for tissue repair. Overall, the results of the current study proved for the first time that the implantable scaffold for long-term confirms the well-being of these rats and is correspondence to biocompatibility ISO standards and can be further developed for medical devices application.

The detached stump of the torn anterior cruciate ligament adheres to the femoral notch wall and then to the posterior cruciate ligament within 6 months from injury.

PURPOSE: To evaluate the progressive changes in the morphology of traumatic ruptures of the anterior cruciate ligament (ACL) over time. A secondary objective was evaluating their correlation with meniscal tears or chondral lesions. METHODS: The study included one hundred and one patients who underwent ACL reconstruction surgery of the knee after a definite date of injury. The torn ACL remnant morphological pattern was assessed and classified during arthroscopy. A correlation analysis was performed between the pathological features of the remnant and the time length from injury. In addition, correlation between ACL remnant subtypes and meniscal tears or chondral lesions was evaluated. RESULTS: At surgery there were four distinct ACL tear morphological patterns that were correlated to the time span from injury (r = 0.61, p < 0.001) and ended with scarring of the femoral remnant to the posterior cruciate ligament. The early pattern was noticed within median time of 2.6 months from injury and appeared as a separate stump with no scar tissue. The following two patterns appeared within 6 months from injury and were characterized by adhesion of scar tissue to different locations in the femoral notch. The last morphological pattern appeared as adherence of the ACL stump to the posterior cruciate ligament. This pattern was seen in some patients within 6 months from injury but was the dominant pattern later on and was also correlated with meniscal tears. CONCLUSIONS: During the first 3 months from injury the gross morphological features of the torn ACL remnant showed no scar. This phase was followed by scarring of the femoral remnant at first to the femoral notch, and eventually to the posterior cruciate ligament within 6 months from injury and later on. Therefore, further research on the healing potential of the human ACL stump and its biological environment should be focused on the first 3 months from injury. STUDY DESIGN: Case series; Level of evidence, 4.

Stability of extracapsular hip fracture: Does it affect rehabilitation outcome of post-acute patients?

BACKGROUND: Various factors have been shown to affect rehabilitation outcome of hip fractured patients. The degree of extracapsular fracture stability may also affect functional recovery. The aim of our study was to assess the relationship between extracapsular hip fracture stability and rehabilitation outcome in a post-acute setting. METHODS: A retrospective cohort study of 144 hip fractured patients was carried out in a post-acute geriatric rehabilitation center from 1/2014 to 6/2015. The main outcome measures were the Functional Independence Measure (FIM) instrument, motor FIM (mFIM), Montebello Rehabilitation Factor Score (MRFS) on the mFIM and length of stay (LOS). The associations between patients with stable vs. unstable and clinical, demographic and comorbidity variables, were assessed by the Mann-Whitney U and chi-square tests. A multiple linear regression model was used to estimate the association between fracture stability and LOS score after controlling for sociodemographic characteristics and chronic diseases. RESULTS: Rehabilitation outcomes (FIM and mFIM score changes, mFIM MRFS) were found independent of extracapsular hip fracture stability. Patients with an unstable fracture presented with a significantly longer LOS compared with a stable fracture (p = .008). Multiple linear regression analysis showed that fracture stability was significantly associated with LOS after adjustment for confounding demographic, clinical and functional variables (p = .009). CONCLUSION: Patients with unstable extracapsular hip fractures may require a prolonged rehabilitation period in order to achieve the same functional gain as patients with stable fractures.

Increased Risk of Heterotopic Ossification Following Revision Hip Arthroplasty for Periprosthetic Joint Infection.

BACKGROUND: To investigate whether surgery for Periprosthetic Joint Infection (PJI) of the hip, the number of procedures and their duration contribute to risk of Heterotopic Ossification formation. METHODS: 56 patients with hip PJI undergoing one-stage (10) or two-stage (46) exchange arthroplasty were matched to 112 patients undergoing revision arthroplasty for aseptic failure based on age, gender, body mass index (BMI), surgical approach (all direct lateral) and date of surgery (2006-2013). Patients with Paget's disease and ankylosing spondylitis, or preoperative HO were excluded. Perioperative pain management included use of the anti-inflammatory medications in all patients without prophylactic radiotherapy. Six-month postoperative radiographs were reviewed based on Brooker classification. RESULTS: The incidence of overall HO in PJI and aseptic groups was 84% (47/56) and 11% (12/112), respectively. High grade HO (grades 3 and 4) in PJI and aseptic groups were 25% (24/56) and 4% (4/112), respectively. PJI was an independent risk factor for HO in the multivariate analysis (odds ratio of 9.3, 95% CI: 2.9-29.9, P<0.001). CONCLUSION: Patients undergoing surgical treatment of hip PJI seem to be at increased risk of developing HO compared to aseptic failure. HO prophylaxis regimens may be recommendable in eligible patients undergoing surgical intervention for PJI of the hip. LEVEL OF EVIDENCE: IV.

Medial forefoot fillet flap for primary closure of transmetatarsal amputation: A series of four cases.

Amputation of the forefoot is a salvage procedure for several forefoot acute or chronic infection. A good, sensate and durable skin cover is important for quicker and better rehabilitation. The use of filleted flaps (or "spare parts technique") has been published in the past as a creative technique. The purpose of this article is to introduce a reproducible, pre-planned, technique that requires less creativity for the use of the "spare parts". The authors describe a case series of 4 patients with deep infection and osteomyelitis of the forefoot, without involvement of the medial skin that underwent two staged procedure for transmetatarsal amputation with medial forefoot fillet flap. The first procedure was amputation of the 4 lesser metatarsal and the wound was left open. After a few days the second operation was done with amputation of the first metatarsal bone and using the filleted medial skin and subcutaneous tissue for closure of the wound. In conclusion the medial fillet flap is an effective method of covering large wounds after partial, lateral forefoot amputation. This method shortens the healing time of the patient, and in hospital stay. The authors recommend using the staged method when dealing with diabetic patients with partial, central and lateral forefoot deep infection and/or necrosis.

A comparison of treatment setting for elderly patients with hip fracture, is the geriatric ward superior to conventional orthopedic hospitalization?

INTRODUCTION: Hip fractures in the elderly are a major cause of morbidity and mortality. The treatment settings of these patients may change their outcomes. The aim of this study is to compare the outcomes of patients with displaced femoral neck fractures who were admitted to the orthopedic vs. geriatric wards. PATIENTS AND METHODS: A retrospective study was conducted on 217 consecutive older patients with 219 displaced femoral neck fractures admitted either to the orthopedic or the geriatric ward between Jan. 2013 and Jun. 2015. Information regarding demographic, medical history, surgical management, hospitalization, and one year readmissions and mortality data was retrieved from electronic charts. RESULTS: 102 hemiarthroplasty patients were admitted to the orthopedic ward and 117 to the geriatric ward. Patients' characteristics, including age, living arrangements, mobility status and the Charlson Comorbidity Index were similar between groups. Patients from the orthopedic ward had shorter hospitalization time (9±5.1 vs. 10.8±6.7days, p=0.022) and presented a lower in-hospital complication rates (0.6±0.96 vs. 1±1.9, p=0.022), namely fewer events of urinary retentions, urinary tract infections and pneumonias (8.8% vs. 23.9%, p=0.004, 3.9% vs. 14.5%, p=0.010 and 2.9% vs. 12.2%, p=0.034, respectfully). Readmission rates were similar. Neither in hospital nor one year mortality rates differed between groups. CONCLUSIONS: Our study found that geriatric care was not superior to orthopedic directed management in the treatment of elderly patients with hip fractures in terms of in-hospital complications, and hospitalization times.

Tritanium acetabular wedge augments: short-term results.

BACKGROUND: Reconstruction of acetabular defects in total hip arthroplasty (THA) presents a great challenge to orthopaedic surgeons. Previous studies have reported on the use and outcomes of trabecular metal acetabular augments for the reconstruction of acetabular defects. However, no study has been conducted evaluating the short-term results of tritanium acetabular wedge augments for the reconstruction of acetabular defects in THA. METHODS: A retrospective study was conducted using a prospective database at a single institution including primary and revision THA patients from January 2013 to December 2014. Patients were included if they received a tritanium acetabular wedge augment system and had a minimum of 2-year follow-up (average 2.2 years ±0.3, range, 2-2.6 years). Demographic data and outcomes data [Harris Hip Score-HHS and Short Form (SF)-36] was collected. Radiographic data was also collected on THA revision cases (Paprosky classification), developmental dysplasia of the hip (DDH) cases (Crowe classification), and radiographic follow-up using DeLee and Charnley's classification system. RESULTS: There were 4 revision THA patients, 3 DDH patients, and 1 patient with posttraumatic arthritis. At the latest radiographic follow-up, there were no lucent lines in DeLee and Charnley Zones I, II or III. During the follow-up period, there was no open revision surgery. The SF-36 physical score significantly improved from preoperative measurement (29.6±2.2) to postoperative measurement (52.2±8.7, P=0.003), and the SF-36 mental score also significantly improved from preoperative assessment (34.5±4.5) to postoperative assessment (52.2±7.5, P=0.003). Total HHS scores also significantly improved postoperatively (P=0.02), with significant improvements in both the pain score (P=0.01) and function score (P=0.02). CONCLUSIONS: Tritanium acetabular wedge augments in this short follow-up case series exhibit high clinical outcome scores, no radiographic lucency, and no early failures.

Aspirin Can Be Used as Prophylaxis for Prevention of Venous Thromboembolism After Revision Hip and Knee Arthroplasty.

BACKGROUND: The optimal prophylaxis for prevention of venous thromboembolic events (VTEs) after revision total joint arthroplasty (TJA) remains unknown. The objective of this study was to evaluate whether aspirin, known to be effective for prevention of VTEs after primary arthroplasty, is also effective after revision TJA. METHODS: We studied 2997 consecutive patients who underwent revision TJA between 2005 and 2013 and were treated with intermittent pneumatic compression devices and either aspirin (534 patients) or warfarin (2463 patients) for VTE prophylaxis. Pertinent data including the incidence of symptomatic VTEs, bleeding events, infection, and mortality were retrieved from our prospectively collected database. RESULTS: The incidence of symptomatic VTEs was significantly higher in the warfarin group at 1.75% (43 of 2463) compared with 0.56% (3 of 534) in the aspirin group (odds ratio: 3.2; 95% CI: 1.03-16.3; P = .03). There was a higher rate of bleeding events with administration of warfarin (1.5%) compared with aspirin (0.4%; P = .02; odds ratio: 4.1; 95% CI: 1.2-34.0). The rate of surgical site infection was similar between the aspirin group and the warfarin group (1.61% and 1.70%, respectively). CONCLUSION: Administration of aspirin as prophylaxis against VTEs after revision arthroplasty may be a viable option as it appears to be more effective than warfarin in prevention of symptomatic VTEs and is associated with a lower rate of complications.

Tranexamic Acid Can Be Administered to Arthroplasty Patients Who Receive Aspirin for Venous Thromboembolic Prophylaxis.

BACKGROUND: Venous thromboembolism (VTE) is not uncommon after total joint arthroplasty (TJA). Various prophylactic agents have been used to minimize this complication after TJA. Numerous studies have demonstrated that acetylsalicylic acid (ASA) has equivalent efficacy to other agents in preventing VTE after TJA. However, some have expressed theoretical concern that ASA may not be an adequate VTE prophylaxis in TJA patients receiving tranexamic acid (TA), which is an antifibrinolytic agent. The purpose of the study was to assess the safety and efficacy of administering systemic TA in TJA patients who also received ASA for VTE prophylaxis. METHODS: A retrospective study was conducted on 2835 consecutive patients (1678 receiving TA and 1157 not receiving TA) who underwent primary or revision TJA between January 2013 and June 2014 and also received aspirin for VTE prophylaxis. The incidence of symptomatic deep vein thrombosis and pulmonary embolism was evaluated. RESULTS: Blood loss and transfusion rates were significantly lower in the TA group compared to the non-TA group (P < .0001, P = .017, respectively). The incidence of VTE, bleeding events, and wound complications was similar (P > .05) between the groups. CONCLUSION: In patients undergoing TJA who receive ASA for VTE prophylaxis, TA reduces bleeding and transfusions without increasing the incidence of subsequent VTE.

The Sphygmomanometer Pain Test: A Simple Method for Identifying Patients at Risk of Excessive Pain after Total knee Arthroplasty.

BACKGROUND: Despite the overall success of total knee arthroplasty (TKA), a relatively large proportion of patients remain dissatisfied with the outcome. We hypothesized that patients with a lower threshold for pain were more likely to have worse outcomes after TKA. METHODS: Forty-eight consecutive patients with primary knee osteoarthritis graded a standardized painful stimulus caused by inflating a sphygmomanometer placed on the forearm, on a visual analog scale (VAS) scale before their TKA. We compared the VAS scores to patients' Knee Society scores and Knee Society function scores 2 years after TKA. RESULTS: Patients with a severe VAS score (>74 mm) had significantly worse Knee Society scores compared to patients with mild (0-44 mm) and moderate (45-74 mm) VAS scores (55 ± 20.5 vs 81.5 ± 11.1 and 84.8 ± 13, respectively, P = .04) and worse Knee Society Function scores (34 ± 20.7 vs 75.2 ± 17.3 and 77 ± 17.4, respectively, P = .027) at 2 years after TKA. CONCLUSIONS: Patients with a lower threshold for pain, as determined by a standardized painful stimulus, are more likely to have lower Knee Society pain and function scores after TKA.

Periprosthetic joint infection: the algorithmic approach and emerging evidence.

Periprosthetic joint infections (PJIs) continue to affect patients, result in accelerated mortality, and consume approximately $1 billion of annual healthcare resources. The future of otherwise successful total joint arthroplasties can be jeopardized by PJI. In recent years, the issue of hospital-acquired infections has gained increasing attention in the United States and the rest of the world, and numerous efforts are being made to address this problem. The orthopaedic community continues to partner with societies, professional organizations, and industry to address this challenge. Recently, an international group of more than 300 surgical experts produced a 350-page document that outlines some of the best practices and identifies the evidence gap related to the management of PJIs. The document, using an algorithmic approach, outlines effective strategies for the prevention, diagnosis, and surgical management of PJIs. It is anticipated that the application of this algorithmic approach will lead to a reduction in the incidence of PJIs, will allow clinicians to diagnose PJI effectively and expeditiously, and will improve the outcome of patients affected by PJIs.

Tourniquet Release Prior to Dressing Application Reduces Blistering Following Total Knee Arthroplasty.

Skin blisters occur in up to 20% of patients after total knee arthroplasty (TKA). Tourniquet release results in a limb volume increase of 10%. We hypothesized that releasing tourniquet before application of circumferential dressing will decrease blister formation. A prospective study was conducted on 135 consecutive primary TKAs. The tourniquet was released immediately after wound closure to allow for re-perfusion and then a dressing was applied. These patients were compared to a historical cohort of 200 primary TKAs, where the tourniquet was released after application of dressing. There was a significant difference in the incidence of blisters between the two groups [Late 7.5% (15/200) vs early release 2.2% (3/135) P=0.028]. Releasing the tourniquet prior to dressing application has reduced the incidence of blistering following TKA.